MEDICARE: DWAN SHIRMELLE MABRY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	MD.022096	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104822782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DWAN SHIRMELLE MABRY M.D.

Provider Business Mailing Address
First Line	:	15748 MEDICAL ARTS DR
Second Line	:
City	:	HAMMOND
State	:	LA
Zip	:	70403-1446
Country	:	US
Telephone Number	:	985-542-0663
Fax Number	:	985-542-7010

Provider Business Practice Location Address
First Line	:	15748 MEDICAL ARTS DR
Second Line	:
City	:	HAMMOND
State	:	LA
Zip	:	70403-1446
Country	:	US
Telephone Number	:	985-542-0663
Fax Number	:	985-542-7010

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	09/19/2013

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